Medical School in the UK, Residency in the US
Today’s Medical Education Monday post is one I have been looking forward to reading since he offered to write it for me a few weeks ago! Nick Bennett (@peds_id_doc) is a Pediatric Infectious Disease Fellow in Syracuse, NY and he has a very unique perspective to share with the Mind On Medicine readers today. Dr. Bennett went to medical school (and got his PhD…overachiever…does that mean we call him Doctor Dr. Bennett? I think it does.) in Cambridge, UK, but chose to do his residency in the United States. Medical school in one country, residency in another – what a unique and valuable addition to to this series!! In addition to being a bug-killer extraordinaire, he is interested in teaching communication skills, antibiotic stewardship and software-driven data analysis (from what I’ve gathered on Twitter he’s the owner of some geeky computer skills – something I’ve come to regard highly after marrying a software developer – that stuff is no joke). I hope his information can help someone looking to do something similar, but I can assure you that his story is a great read even if you never plan to practice medicine somewhere other than your country of training…actually even if you never plan to practice medicine at all.
I’m in the interesting position of someone who went to medical school in one country (UK) but completed residency in another (USA). My reasons for doing so are, on the surface, fairly simple (my wife is an American) but it goes a bit deeper than that. One issue that was important was the fact that in the UK the junior doctor jobs often involve moving from hospital to hospital, spending only a few months in the same place. The alternative was to move once and stay at the same hospital for several years. It seemed like a simple decision!
The problem I immediately ran into was – just how the heck do I do this? There was absolutely no careers advice for those of us who wanted to leave the NHS (National Health Service). I’d even been to careers advice forums where the speaker opened with, “This is really for all the scientists here, as doctors have it pretty much sorted out.” Yeah, thanks.
Searching online revealed two basic hurdles – exams and visas. The US assumes that every other medical school in the world has exams that aren’t reliable. You not only have to graduate from your medical school (if it is on the list of acceptable schools!) you have to pass US medical school exams as well – the USMLE Step 1 (the test I take Friday) and 2. For most people this is an annoying formality, but there are two issues here: Step 1 is basic science – you may be many years from your pre-clinical training and hence quite rusty (as I was) by the time you take it – and Step 2 has a heavy US bias, so you have to re-learn minor facts of epidemiology as well as have a basic knowledge of US geography and the medical conditions, typically infections, that are more common in certain states.
The exams are required for certification by the ECFMG – the Educational Commission for Foreign Medical Graduates. Along with your medical school records, passing the Step exams is needed to obtain ECFMG certification, which is required to start a training program in the US as a Foreign Medical Graduate (FMG). It is quite expensive in terms of fees and exam costs, but if you want the training you have to invest the money.
The second issue of a Visa was one I was thankfully helped with by marrying an American! The more typical approach is to obtain a H1B or J1 training visa. These are sponsored by the residency program or the ECFMG, so you have to have been accepted by the program before that can move forward. Not every program will sponsor training visas so focus your efforts on those that do. FMGs are often at a competitive disadvantage compared to US graduates, but some programs are very supportive so it can pay to do your homework about a particular place to find out how they stand on that issue. If you have contacts in a residency program in the US that’s probably the best way to get the inside scoop.
I was very lucky in getting the program I wanted – I was taken “outside of the match” which means I didn’t have to deal with the NRMP (National Resident Match Program), which I gather can be quite stressful and complex, especially for non-US graduates. As such, I’m rather odd in that I can’t offer any advice on visas or matching! I did it through networking and spending time here as a student doing an elective. That kind of exposure is priceless when it comes to applying for a residency position (spending time doing away rotations in places you want to do residency is sound advice for ALL medical students, not just for those looking to go to a new country to finish their training).
There are a few websites out there with advice on moving to the US. They’re worth reading to be prepared for some of the inevitable culture shock. Oddly enough, the effect was perhaps weirder coming from the UK. Enough of the lifestyle and society was similar to the UK that when something WAS different it seemed more of a surprise. Silly things like having to add sales tax onto prices and paying for checking (current) accounts were hard to get used to, you get used to it, though.
Once I was here a few things became quickly apparent. The first was that although it seemed as if my medical school training gave me an excellent basic medical science background, but I felt wholly unprepared for actual patient care. The US students were given more responsibility and seemed more involved in patient care that I had been. The other FMGs that were starting with me tended to have already completed a residency in their own country. I was lucky in having a graded experience working up from the newborn nursery to the ER and excellent senior residents, but I know that had I started out in the ER things might not have gone so well! My learning curve was near vertical, but I kept my head above water enough to keep going. Once I was settled in it was also clear that despite all I had heard about the “evil US profit-driven healthcare system”, the actual practice of medicine was basically the same as it was in the UK. Docs still made decisions based on best practice and in the patient’s best interests, at least in the academic setting. Only rarely did insurance ever come into play – usually when patients didn’t have any and we had to cut corners to save them some money.
Later, as a Fellow, I ran into the issue far more frequently, when having to obtain “prior authorization” for treatments that insurance companies would rather not pay for. I’ve also heard and seen more discouraging practices from the non-academic world, which although not unique to the US are far less likely in the system I came from. Everything from pharmacy costs to malpractice premiums is shifted upwards, and it’s easy to see how the US ends up spending twice as much as any other developed country for no additional benefit.
There were several advantages to coming here that I really didn’t anticipate. Back in the UK I recall asking my research supervisor how I could get to be someone like him. He replied that I should focus on medicine for the first 10 years or so before trying to come back to research. When I asked the same of my mentor here in the US he said “Well, you’ll have to wait until at least the second year of Residency…!” As it happens, in my Intern year I started writing online medical review topics, helped out with clinical trials and started a new medical education initiative for the students. It seems as if people are very willing here to support junior doctors in the kinds of extra-curricular activities that would otherwise have to be put off for years in the UK. That’s not to say that every FMG becomes a world-famous clinical educator or researcher, but that it just seemed to me that the opportunities were better for me here. In addition, it’s very clear that people do all kinds of things with their medical training here. In the UK I felt as if I was being channeled into the NHS and it seemed there was no way to easily merge education or research into my daily activities. In the US it is equally valid to choose private practice as it is to choose academics, industry, or government work – in fact, many mix and match.
I think I got a great education from the UK, and I didn’t leave specifically because I couldn’t get what I wanted there – it was for personal reasons, but it turns out that making this move to the US was a really great professional decision, too.